Nokea
A licensed practical/vocational (LPN/VN) nurse assists the behavioral health unit's registered nurse (RN). Which task can the RN appropriately delegate to the LPN/VN?
- A. Alcohol withdrawal screening on a client going through detoxification
- B. Medication administration to a client with a nasogastric tube
- C. Suicide assessment on a newly admitted client
- D. Educating a client on newly prescribed citalopram
Correct Answer: B
Rationale: Medication administration via nasogastric tube (B) is within the LPN’s scope. Alcohol withdrawal screening (A), suicide assessment (C), and education on new medications (D) require RN-level assessment and teaching skills.
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The nurse is caring for a client recovering from hip surgery who needs to regain strength to climb the flight of stairs leading to their bedroom at home. The nurse should recommend a referral to a
- A. physical therapist (PT).
- B. nutritionist.
- C. C. case manager.
- D. D. occupational therapist (OT).
Correct Answer: A
Rationale: A physical therapist (A) specializes in improving strength and mobility, essential for stair climbing post-hip surgery. Nutritionists (B) focus on diet, case managers (C) coordinate care, and occupational therapists (D) address daily living activities.
The nurse is triaging a group of pediatric clients. The nurse should first see the client who is
- A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.
- B. drooling and experiencing difficulty with swallowing.
- C. experiencing a temperature of 101.1°F (38.4°C) and a headache.
- D. reporting excessive thirst and has a thready peripheral pulse.
Correct Answer: B
Rationale: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.
The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse’s priority?
- A. Assess bilateral pedal pulses
- B. Apply a sandbag to stabilize the site
- C. Administer prescribed bolus of intravenous (IV) fluids
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Bradycardia and hypotension post-PCI sheath removal (D) suggest a vasovagal response or bleeding, requiring a fluid bolus (C) to stabilize circulation, per ACLS guidelines. Pulse assessment (A), sandbag application (B), and head elevation (D) are secondary or inappropriate.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with pericarditis who reports increasing chest pain while laying down flat.
- B. with cystic fibrosis who has a temperature of 102.5°F (39.2°C).
- C. who has rhinosinusitis and is reporting facial pain that increases when bending forward.
- D. who has hypertrophic cardiomyopathy and has dyspnea after ambulating in the hallway.
Correct Answer: A
Rationale: Increasing chest pain when lying flat in pericarditis (A) suggests worsening pericardial effusion, a life-threatening condition requiring immediate assessment. Fever in cystic fibrosis (B), sinusitis pain (C), and dyspnea in cardiomyopathy (D) are less urgent.
The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning. The nurse should take which priority action?
- A. Move the client outdoors
- B. Notify the primary healthcare provider (PHCP)
- C. Auscultate the client's lung sounds
- D. Assess the client's pulse oximetry
Correct Answer: A
Rationale: Moving the client outdoors (A) is the priority to remove them from the carbon monoxide source, preventing further toxicity. Notifying the PHCP (B), auscultating lungs (C), and assessing oximetry (D) follow after ensuring safety, as oximetry may be falsely normal in CO poisoning.